1
|
Zhang D, Jiang L, Chen YN, Pan MF. The diagnostic value of contrast-enhanced transcranial Doppler and contrast-enhanced transthoracic echocardiography for right to left shunt in patent foramen ovale: a systematic review and meta-analysis. Front Neurol 2024; 15:1447964. [PMID: 39157064 PMCID: PMC11327031 DOI: 10.3389/fneur.2024.1447964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/25/2024] [Indexed: 08/20/2024] Open
Abstract
Purpose To evaluate and compare the diagnostic value of contrast-enhanced transcranial Doppler (c-TCD) and contrast-enhanced transthoracic echocardiography (c-TTE) for right to left shunt (RLS) in patent foramen ovale (PFO) by meta-analysis. Methods The literature included in the Cochrane Library, PubMed, and Embase were searched by using "contrast-enhanced transcranial Doppler (c-TCD), contrast-enhanced transthoracic echocardiography (c-TTE), patent foramen ovale (PFO), and right to left shunt (RLS)" as the keywords from inception through April 30, 2024. The diagnostic accuracy research quality assessment tool (QUADAS-2) was used to evaluate the quality of the included literature. The combined sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and Diagnostic odds ratio (DOR) were pooled, and a comprehensive ROC curve analysis was performed. Statistical software StataSE 12.0 and Meta-Disc 1.4 were used for data analysis. Results A total of 8,536 articles were retrieved, and 9 articles that met all inclusion criteria were included in this meta-analysis. The meta-analysis results show that the combined sensitivity, specificity, PLR, NLR, DOR, and area under the SROC curve of c-TCD for the diagnose of PFO-RLS were 0.91 (95% CI, 0.88-0.93), 0.87 (95% CI: 0.84-0.91), 6.0 (95% CI, 2.78-12.96), 0.10 (95% CI, 0.06-0.18), 91.61 (95% CI, 26.55-316.10), and 0.9681, respectively; the corresponding values of c-TTE were 0.86 (95% CI, 0.84-0.89), 0.88 (95% CI, 0.84-0.91), 5.21 (95% CI, 2.55-10.63), 0.16 (95% CI, 0.09-0.31), 71.43 (95% CI, 22.85-223.23), and 0.9532. The ROC curve shows that c-TCD has slightly higher diagnostic value for PFO than c-TTE, but there is no significant statistical difference (Z = 0.622, p > 0.05). Deek funnel pattern showed no significant publication bias. Conclusion Both c-TCD and c-TTE have high diagnostic values for PFO-RLS. However, c-TCD has slightly higher sensitivity and lower specificity in diagnosing PFO-RLS compared to c-TTE.Systematic review registration: identifier [CRD42024544169].
Collapse
Affiliation(s)
| | | | | | - Mei-Fang Pan
- Department of Ultrasound, Xiangcheng People's Hospital, Suzhou, China
| |
Collapse
|
2
|
Xu K, Tian X, Hao M, Li Y, Zhang J, Wong RHL, Othmani A, Zhang Q. Diagnostic value of contrast-enhanced ultrasonography for patent foramen ovale detection. J Thorac Dis 2024; 16:3282-3290. [PMID: 38883615 PMCID: PMC11170417 DOI: 10.21037/jtd-24-330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/26/2024] [Indexed: 06/18/2024]
Abstract
Background Patent foramen ovale (PFO) has been associated with migraine, cryptogenic stroke (CS), and hypoxemia. However, which examination method is most reliable remains controversial. This study sought to investigate the diagnostic value of contrast-enhanced ultrasonography (cU), including contrast-enhanced transcranial Doppler (cTCD), contrast transthoracic echocardiography (cTTE), and contrast transesophageal echocardiography (cTEE), for PFO; and to determine the best diagnostic strategy. Methods This retrospective observational study included a total of 147 consecutive patients suspected PFO at The First Hospital of Shanxi Medical University between October 2019 and January 2022. The patients also underwent cTCD, cTTE, and cTEE examinations. The standard for the diagnosis of PFO was confirmation of the presence of PFO by color Doppler flow signals or contrast microbubbles (MBs) passing through the foramen ovale. Results A total of 123 patients were diagnosed with PFO and 24 patients without PFO during the study period. The detectable rates of cTCD, cTTE, and cTEE were 120 (97.56%), 110 (89.43%), and 121 (98.37%), respectively. The sensitivity between cTCD and cTEE for PFO were comparable [97.56%, 95% confidence interval (CI): 92.5% to 99.4% vs. 98.37%, 95% CI: 93.7% to 99.7%; P>0.99], and the sensitivity of both were higher than that of cTTE (89.43%, 95% CI: 82.3% to 94.0%; P=0.02 and P=0.001, respectively). In addition, the specificity of cTEE for PFO was significantly higher than that of cTCD (100%, 95% CI: 82.3% to 100.0% vs. 75.00%, 95% CI: 53.0% to 89.4%; P<0.001) and cTTE (100%, 95% CI: 82.3% to 100.0% vs. 75.00%, 95% CI: 53.0% to 89.4%; P<0.001). Further, the semi-quantitative classification ability of cTCD for PFO with right-to-left shunt (RLS) was significantly higher than that of cTTE and cTEE (P=0.02 and P<0.001, respectively), and that of cTTE was significantly higher than that of cTEE (P=0.01). The Spearman analysis showed that the degree of RLS was positively correlated with the inner diameter of the PFO (r=0.695, P<0.001). Conclusions The combination of cTCD and cTEE may provide a favorable strategy for the diagnosis of PFO.
Collapse
Affiliation(s)
- Kun Xu
- The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xiaoguang Tian
- The Fifth Hospital of Shanxi Medical University, Taiyuan, China
| | - Meifang Hao
- The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Yiying Li
- The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Jingxuan Zhang
- The First Hospital of Shanxi Medical University, Taiyuan, China
| | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Adrianna Othmani
- The Clinical Department of Cardiac and Vascular Diseases with the Intensive Cardiac Supervision Subdivision, John Paul II Hospital, Institute of Cardiology, Collegium Medicum of the Jagiellonian University in Cracow, Cracow, Poland
| | - Quanbin Zhang
- The Sixth Hospital of Shanxi Medical University, Taiyuan, China
| |
Collapse
|
3
|
Tian L, Zhang M, Nie H, Zhang G, Luo X, Yuan H. Contrast-enhanced transcranial doppler versus contrast transthoracic echocardiography for right-to-left shunt diagnosis. J Clin Monit Comput 2023; 37:1145-1151. [PMID: 36808597 PMCID: PMC10520160 DOI: 10.1007/s10877-023-00979-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 01/28/2023] [Indexed: 02/21/2023]
Abstract
RLS can be diagnosed using US, CT angiography, and right heart catheterization. However, most reliable diagnostic modality remains undetermined. c-TCD was more sensitive than c-TTE in the diagnosis of RLS. This was true especially for the detection of provoked shunts or mild shunts. c-TCD can be used as the preferred screening method for RLS.
Collapse
Affiliation(s)
- Li Tian
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China
| | - Min Zhang
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China.
| | - Hongjun Nie
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China
| | - Guanling Zhang
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China
| | - Xiaoyan Luo
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China
| | - Huaiyun Yuan
- Department of Ultrasound Diagnostics, The Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, 161 Shaoshan South Road, Yuhua District, 410004, Changsha, Hunan, People's Republic of China
| |
Collapse
|
4
|
Yao Q, Xiong H, Zhang D, Ren S, Qi W, Zou X, Zhao Y, Huang S, Wang J, Cao L. Synchronous multimode ultrasound for assessing right-to-left shunt: a prospective clinical study. Front Neurol 2023; 14:1148846. [PMID: 37409021 PMCID: PMC10319494 DOI: 10.3389/fneur.2023.1148846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/31/2023] [Indexed: 07/07/2023] Open
Abstract
Background Right-to-left shunt (RLS) is associated with several conditions and causes morbidity. In this study, we aimed to evaluate the effectiveness of synchronous multimode ultrasonography in detecting RLS. Methods We prospectively enrolled 423 patients with high clinical suspicion of RLS and divided them into the contrast transcranial Doppler (cTCD) group and synchronous multimode ultrasound group, in which both cTCD and contrast transthoracic echocardiography (cTTE) were performed during the same process of contrast-enhanced ultrasound imaging. The simultaneous test results were compared with those of cTCD alone. Results The positive rates of grade II (22.0%:10.0%) and III (12.7%:10.8%) shunts and the total positive rate (82.1748%) in the synchronous multimode ultrasound group were higher than those in the cTCD alone group. Among patients with RLS grade I in the synchronous multimode ultrasound group, 23 had RLS grade I in cTCD but grade 0 in synchronous cTTE, whereas four had grade I in cTCD but grade 0 in synchronous cTTE. Among patients with RLS grade II in the synchronous multimode ultrasound group, 28 had RLS grade I in cTCD but grade II in synchronous cTTE. Among patients with RLS grade III in the synchronous multimode ultrasound group, four had RLS grade I in cTCD but grade III in synchronous cTTE. Synchronous multimode ultrasound had a sensitivity of 87.5% and specificity of 60.6% in the patent foramen ovale (PFO) diagnosis. Binary logistic regression analyses showed that age (odds ratio [OR] = 1.041) and risk of paradoxical embolism score ≥ 7 (OR = 7.798) were risk factors for stroke recurrence, whereas antiplatelets (OR = 0.590) and PFO closure with antiplatelets (OR = 0.109) were protective factors. Conclusion Synchronous multimodal ultrasound significantly improves the detection rate and test efficiency, quantifies RLS more accurately, and reduces testing risks and medical costs. We conclude that synchronous multimodal ultrasound has significant potential for clinical applications.
Collapse
Affiliation(s)
- Qingyang Yao
- Department of Neurology, The First Hospital of Quanzhou Affliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Huahua Xiong
- Department of Ultrasound, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Ultrasound, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Daxue Zhang
- School of Nursing, Anhui Medical University, Hefei, China
| | - Shuqun Ren
- School of Nursing, Guangxi University of Chinese Medicine, Nanning, China
| | - Wenwei Qi
- Tianjin Institute of Cardiology, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Xia Zou
- Department of Ultrasound, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Ultrasound, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Yingying Zhao
- Department of Ultrasound, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Ultrasound, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Shanshan Huang
- Department of Ultrasound, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Ultrasound, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Jing Wang
- Department of Ultrasound, Shenzhen Second People’s Hospital, Shenzhen, China
- Department of Ultrasound, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, Shenzhen, China
- College of Pharmacy, Changsha Medical University, Changsha, China
| |
Collapse
|
5
|
Hutayanon P, Muengtaweepongsa S. The Role of Transcranial Doppler in Detecting Patent Foramen Ovale. JOURNAL FOR VASCULAR ULTRASOUND 2023; 47:33-39. [DOI: 10.1177/15443167221108512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/03/2023]
Abstract
Air embolic signals detected in the intracranial arteries using transcranial Doppler after intravenous injection of agitated saline bubbles indicate right-to-left cardiac shunting. They prove that emboli from venous sites can bypass the lungs and flow to the intracranial arteries. The Valsalva maneuver immediately after an intravenous injection of agitated saline bubbles helps the air bubbles pass through the shunt. If the air embolic signal appears in the intracranial arteries without the Valsalva maneuver, the shunting is highly significant to the etiology of embolism. Transcranial Doppler to detect air embolic signals after intravenous injection of agitated saline bubbles may not be mandatory to diagnose and treat patent foramen ovale; however, as with echocardiography, transcranial Doppler is considered a noninvasive, convenient, and low-cost investigation. The test should be helpful to confirm the significance of the corresponding patent foramen ovale.
Collapse
|
6
|
Hitzeroth J, van der Bijl P, Michel F, Meel R, Cupido BJ, Klug E. SA Heart consensus statement on closure of patent foramen ovale 2021. Cardiovasc J Afr 2023; 34:35-39. [PMID: 35687070 PMCID: PMC10392800 DOI: 10.5830/cvja-2022-009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 02/07/2022] [Indexed: 06/07/2023] Open
Abstract
A patent foramen ovale (PFO) is associated with numerous clinical conditions. The most severe of these is cryptogenic stroke. This consensus statement aims to provide a clinical guideline on which patients should be offered PFO closure.
Collapse
Affiliation(s)
- J Hitzeroth
- Medical School, University of Cape Town, Cape Town, South Africa
| | | | - F Michel
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - R Meel
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - B J Cupido
- Medical School, University of Cape Town, Cape Town, South Africa
| | - E Klug
- Department of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| |
Collapse
|
7
|
Xiao L, Yan YH, Ding YF, Liu M, Kong LJ, Hu CH, Hui PJ. Evaluation of right-to-left shunt on contrast-enhanced transcranial Doppler in patent foramen ovale-related cryptogenic stroke: Research based on imaging. World J Clin Cases 2022; 10:143-154. [PMID: 35071514 PMCID: PMC8727250 DOI: 10.12998/wjcc.v10.i1.143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 11/04/2021] [Accepted: 11/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cardiogenic embolism caused by patent foramen ovale (PFO) is a common etiology of cryptogenic stroke (CS), particularly in young and middle-aged patients. Studies about right-to-left shunt (RLS) detection using contrast-enhanced transcranial Doppler (c-TCD) are numerous. According to the time phase and number of microbubbles detected on c-TCD, RLS can be classified and graded. We hypothesized that the characteristics of an infarction lesion on diffusion-weighted imaging differs when combining the type and grade of RLS on c-TCD in patients with PFO-related CS.
AIM To explore the characteristics of infarction lesions on diffusion-weighted imaging when combining the RLS type and grade determined by c-TCD.
METHODS We retrospectively evaluated CS patients from August 2015 to December 2019 at a tertiary hospital. In total, 111 PFO-related CS patients were divided according to whether RLS was permanent (microbubbles detected both at resting state and after the Valsalva maneuver) or latent (microbubbles detected only after the Valsalva maneuver) on c-TCD. Each group was subdivided into small, mild and large RLS according to the grade of shunt on c-TCD. A normal control group was composed of 33 patients who suffered from simple dizziness. Intragroup and intergroup differences were analyzed in terms of clinical, laboratory and diffusion-weighted imaging lesion characteristics. The correlation between RLS grade evaluated by c-TCD and size of PFO determined by transesophageal echocardiography were also analyzed.
RESULTS In 111 patients with PFO-related CS, 68 had permanent RLS and 43 had latent RLS. Clinical characteristics and laboratory tests were not significantly different among the permanent RLS, latent RLS and normal control groups. The proportion of patients with multiple territory lesions in the permanent RLS group (50%) was larger than that in the latent RLS group (27.91%; P = 0.021). Posterior circulation was more likely to be affected in the latent RLS group than in the permanent RLS group (30.23% vs 8.82%, P = 0.004). Permanent-large and latent-large RLS were both more likely to be related to multiple (Ptrend = 0.017 and 0.009, respectively), small (Ptrend = 0.035 and 0.006, respectively) and cortical (Ptrend = 0.031 and 0.033, respectively) lesions. The grade of RLS evaluated by c-TCD was correlated to the size of PFO determined by transesophageal echocardiography (r = 0.758, P < 0.001).
CONCLUSION Distribution of the infarct suggested the possible type of RLS. Multiple, small and cortical infarcts suggest large RLS induced by a large PFO.
Collapse
Affiliation(s)
- Lei Xiao
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Yan-Hong Yan
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Ya-Fang Ding
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Man Liu
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Li-Juan Kong
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Chun-Hong Hu
- Department of Radiology, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Pin-Jing Hui
- Stroke Center, the First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| |
Collapse
|
8
|
The Efficacy of Contrast Transthoracic Echocardiography and Contrast Transcranial Doppler for the Detection of Patent Foramen Ovale Related to Cryptogenic Stroke. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1513409. [PMID: 32566656 PMCID: PMC7275210 DOI: 10.1155/2020/1513409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 04/11/2020] [Indexed: 11/18/2022]
Abstract
Background Patent foramen ovale (PFO) has been linked to the pathophysiology of cryptogenic stroke. Contrast transesophageal echocardiography (cTEE) is the current gold standard for PFO diagnosis, but it has the disadvantage of being semi-invasive and does not exempt from risks. As a diagnostic test, the efficacy of contrast transthoracic echocardiography (cTTE) and contrast transcranial Doppler (cTCD) is controversial. This study is aimed at investigating the efficacy of cTTE and cTCD versus cTEE in PFO detection, exploring a more cost-effective and reliable method for the diagnosis of PFO related to cryptogenic stroke. Methods From August 2019 to January 2020, a total of 213 patients with suspected PFO were included in our study. All patients underwent cTEE, cTCD, and cTTE examinations. cTTE3 was named for using a cutoff of 3 beats to detect PFO during cTTE, and cTTE5 represented a cutoff of 5 beats. A cutoff of cTCD grade III was named cTCD III. A cutoff of grade IV was named cTCD IV. cTTE3+cTCD IV was used for the combination of a cutoff of 3 beats during cTTE with grade IV of cTCD. cTTE5+cTCD III combined a cutoff of 5 beats during cTTE with cTCD grade III. Taking cTEE as the gold standard, we compared the sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate for PFO detection among the above methods. Results A total of 161 of 213 (76%) patients had PFO confirmed by cTEE. With the spontaneous Valsalva maneuver, the sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate of cTTE3 in PFO diagnosis were 60%, 90%, 44%, and 10%, respectively, and those for cTTE5 were 76%, 78%, 31% and 22%, respectively. The sensitivity, specificity, negative likelihood ratio (-LR), and misdiagnosis rate of cTCD III were 80%, 71%, 29%, and 29%, respectively, while those for cTCD IV were 55%, 90%, 49%, and 10%, respectively. When cTTE and cTCD were combined to diagnose PFO, the specificity and misdiagnosis rate were significantly improved, especially cTTE3+cTCD IV, with 100% specificity and a misdiagnosis rate of 0. Conclusion cTTE or cTCD can be used for preliminary PFO related to cryptogenic stroke findings. The combination of the two methods can improve the specificity of PFO diagnosis, especially using the cutoff of cTTE3+cTCD IV.
Collapse
|
9
|
Tietjen GE, Maly EF. Migraine and Ischemic Stroke in Women. A Narrative Review. Headache 2020; 60:843-863. [DOI: 10.1111/head.13796] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/07/2020] [Accepted: 03/08/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Gretchen E. Tietjen
- Department of Neurology University of Toledo College of Medicine and Life Sciences Toledo OH USA
| | - Emily F. Maly
- Department of Neurology University of Toledo College of Medicine and Life Sciences Toledo OH USA
| |
Collapse
|
10
|
Diagnosis of Patent Foramen Ovale: The Combination of Contrast Transcranial Doppler, Contrast Transthoracic Echocardiography, and Contrast Transesophageal Echocardiography. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8701759. [PMID: 32185222 PMCID: PMC7060853 DOI: 10.1155/2020/8701759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 02/01/2020] [Indexed: 01/27/2023]
Abstract
Objectives To access the distinct values of contrast transcranial Doppler (cTCD), contrast transthoracic echocardiography (cTTE), and contrast transesophageal echocardiography (cTEE) in the diagnosis of right-to-left shunt (RLS) due to patent foramen ovale (PFO) and to define the most practical strategy for the diagnosis of PFO. Methods 102 patients with a high clinical suspicion for PFO had simultaneous cTCD, cTTE, and cTEE performed. The agitated saline mixed with blood was used to detect right-to-left shunt (RLS). Results In all 102 patients, the shunt was detected at rest by cTCD in 60.78% of cases, by cTTE in 42.16%, and by cTEE in 47.06%. The positive results of all 3 techniques with Valsalva maneuver (VM) were significantly improved. cTCD showed higher pick-up rate than cTTE (98.04% vs. 89.22%; χ2 = 12.452, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, t = 3.135, p < 0.05) and the cTEE (98.04% vs. 96.08%; nonsignificant difference) in the diagnosis of PFO. Nevertheless, cTEE, compared with cTTE, underestimated shunting in 44% of patients. The diameter of both PFO entrance and exit was significantly greater in patients with a severe shunt compared with a mild shunt (2.8 ± 1.0 mm vs. 2.0 ± 0.7 mm, Conclusions The best method to diagnose PFO should be the combination of cTCD, cTTE, and cTEE. And cTCD should be applied as the first choice for screening RLS. Then, cTTE should be performed to quantify the severity of the shunt. Last but not least, cTEE should be performed to assess the morphologies of PFO when the closure is planned. The study provides for clinicians the most practical strategy for diagnosing PFO in the future. However, further trials with a large sample size are required to confirm this finding.
Collapse
|
11
|
Cavaliere M, De Luca P, Scarpa A, Ralli M, Bottiglieri P, Cassandro E, Iemma M. SCORE risk scale as a prognostic factor after sudden sensorineural hearing loss. Eur Arch Otorhinolaryngol 2019; 277:953-954. [PMID: 31873775 DOI: 10.1007/s00405-019-05771-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/12/2019] [Indexed: 11/28/2022]
Abstract
Menezes et al. recently published an interesting study on cardiovascular prognostic factors for sudden sensorineural hearing loss (SSNHL), analyzing therapeutic strategies with intravenous and intratympanic corticosteroids and evaluating the application of the Systematic Coronary Risk Evaluation risk scale to classify risk in patients with SSNHL. In addition to intravenous and intratympanic corticosteroids, we would like to stress the role of hyperbaric oxygen therapy (HBOT). The new guidelines on SSNHL and the most recent scientific evidence emphasize the therapeutic role of HBOT. In a previous study, we recommended the use of HBOT in addition to intravenous steroid for patients with idiopathic SSNHL. For the best outcomes, we also recommended starting treatment within 14 days from the onset of SSNHL. In the same article, we discussed potential risk factors for SSNHL. Among cardiovascular risk factors, we suggest the possible association between patent foramen ovale (PFO) and SSNHL. The higher prevalence of PFO in our patients (50%) compared to controls suggests that SSNHL may be attributable to a paradoxical embolism, such as a venous embolism as a result of PFO.
Collapse
Affiliation(s)
- Matteo Cavaliere
- Department of Otolarhinolaryngology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via Madonna di Fatima 53, 84084, Fisciano, Salerno, Italy.
| | - Pietro De Luca
- Department of Otolarhinolaryngology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via Madonna di Fatima 53, 84084, Fisciano, Salerno, Italy
| | - Alfonso Scarpa
- Department of Otolarhinolaryngology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via Madonna di Fatima 53, 84084, Fisciano, Salerno, Italy
| | - Massimo Ralli
- Department of Sense Organs, Sapienza Unviersity of Rome, Rome, Italy
| | - Pompea Bottiglieri
- Department of Intensive Cardiac Therapy, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Ettore Cassandro
- Department of Otolarhinolaryngology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via Madonna di Fatima 53, 84084, Fisciano, Salerno, Italy
| | - Maurizio Iemma
- Department of Otolarhinolaryngology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Via Madonna di Fatima 53, 84084, Fisciano, Salerno, Italy
| |
Collapse
|
12
|
Chen J, Chen L, Hu W, Ni X, Zhang Z, Feng X, Fan Z, Chen C, Qiu F, Shao B. A comparison of contrast transthoracic echocardiography and contrast transcranial Doppler in cryptogenic stroke patients with patent foramen ovale. Brain Behav 2019; 9:e01283. [PMID: 30941931 PMCID: PMC6520470 DOI: 10.1002/brb3.1283] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 03/07/2019] [Accepted: 03/14/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE In recent years, increasing attention has been paid to cryptogenic stroke (CS) caused by the patent foramen ovale (PFO). This study aims to compare contrast transthoracic echocardiography (cTTE) and contrast transcranial Doppler (cTCD) to determine whether cTTE is more suitable and reliable than cTCD for clinical use. METHODS From March 2017 to May 2018, patients who suffered from migraines, stroke, hypomnesis, or asymptomatic stroke found casually were included in our study. Patients with CS were semirandomly divided into two groups (cTTE and cTCD) according to the date of the outpatient visit. Patients with either of the examination above found positive were selected to finish transesophageal echocardiography (TEE). RESULTS In our study, the sensitivities of group cTTE positive (group cTTE+) and group cTCD positive (group cTCD+) did not have any statistical difference (89% vs. 80%, p = 0.236). Focusing on group cTCD+, we discovered that the semiquantitative shunt grading was not correlated with whether a PFO was present or not (p = 0.194). However, once the PFO has been diagnosed, the shunt grading was shown to be related to the width of the gaps (p = 0.032, pdeviation = 0.03). CONCLUSION Both cTTE and the cTCD can be used for preliminary PFO findings. The semiquantitative shunt grading of cTCD and cTTE can suggest the size of the PFO and the next course of treatment. The cTTE may be more significant to a safe PFO (a PFO does not have right-to-left shunts, RLSs). Combining cTTE and TEE could help diagnose PFO and assess CS risk.
Collapse
Affiliation(s)
- Jie Chen
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Luyun Chen
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wangwang Hu
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xianda Ni
- Department of Ultrasonography, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zengrui Zhang
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaowen Feng
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zijian Fan
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Cuiping Chen
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Fengzhen Qiu
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bei Shao
- Department of Neurology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| |
Collapse
|